Medicare Supplement Plan

Effective August 1, 2014

As a Blue Shield Medicare Supplement plan member, you’re eligible for dental or combined dental + vision coverage. Choose a quality plan that fits your needs. We offer

three plan choices designed for the needs of members age 65 and older: two dental PPO plans and one combined dental + vision package. We want to keep you smiling.

more reasons to keep smiling Dental and dental + vision coverage for Medicare Supplement plan members

Dental and dental + vision coverage

Why enroll?It’s a fact that periodontal (gum) disease is linked to other serious health risks such as osteoporosis, heart disease, stroke, and diabetes. When you keep your mouth healthy, you’re also keeping your body healthy.1

Regular dental checkups can help prevent expensive procedures. Maintaining your dental health with a Blue Shield dental plan is the smart and affordable way to protect yourself against costly professional care.

Routine eye exams can also help detect both eye and systemic health issues. When detected early, many conditions can be managed more effectively – with less costly treatments and a better chance for a healthy outcome.

That’s why we offer a dental and vision plan package called Specialty DuoSM *,2 that includes comprehensive dental and vision coverage to give you the additional protection that both your mouth and eyes deserve.

So, with Blue Shield’s dental plans, you can have the dental or the dental + vision coverage you’ve always wanted, at a price you can afford!

More coverage at no extra cost!As a dental PPO plan or Specialty Duo package for Medicare Supplement plan member, you’ll be covered for a third annual teeth-cleaning benefit at no additional charge when using a network provider – that’s one cleaning every four months. Instead of the typical twice-a-year cleaning schedule, this expanded benefit can help you protect your dental health while helping keep major dental services to a minimum.

Did you know…?You may be surprised to learn that more than 90% of all common diseases have oral symptoms.3 In addition, eye exams can often detect serious chronic conditions such as diabetes, hypertension, and high cholesterol.4 Whether you need treatment or just want preventive care, it’s never too late to get on track and choose a Blue Shield dental or combined dental + vision coverage to help maintain your overall health.

* Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).

Save with our dental plans and Specialty Duo packageIt takes just a moment to see what a great value our dental PPO plans offer you. They can pay for themselves in the first year of coverage. The following charts show the potential savings of using a network dentist with either a Blue Shield dental PPO plan or the dental component of the dental + vision package.

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Estimated savings

Description Dental patients without coverage(standard list price for preventive visits)5

Blue Shield Dental PPO 1000 member out-of-pocket costs($35.90/month x 12 months)

Blue Shield Dental PPO 1500 member out-of-pocket costs($45.10/month x 12 months)

Annual individual rates $ 0.00 $ 430.80 $ 541.20

Annual exam $ 118.00 $ 0.00 $ 0.00

Periodic exam $ 101.00 $ 0.00 $ 0.00

1st teeth cleaning $ 118.00 $ 0.00 $ 0.00

2nd teeth cleaning $ 118.00 $ 0.00 $ 0.00

3rd teeth cleaning $ 118.00 $ 0.00 $ 0.00

Complete x-rays $ 168.00 $ 0.00 $ 0.00

Your total cost $ 741.00 $ 430.80 $ 541.20

Your first-year savings $ 310.20 $ 199.80

Dental PPO plans

Estimated additional savings

Description Dental patients without coverage(standard list price)5

Blue Shield Dental PPO 1000 member out-of-pocket costs(network dentist)

Blue Shield Dental PPO 1500 member out-of-pocket costs (network dentist)

Calendar-year deductible $ 0.00 $ 75.00 $ 50.00

One filling $ 213.00 $ 41.50 $ 16.60

Molar root canal $1,336.00 $ 190.50 $ 190.50

High noble metal porcelain crown

$1,439.00 $ 335.00 $ 335.00

Charges above the calendar-year benefit maximum

N/A $ 0.00 $ 0.00

Your total cost $2,988.00 $ 642.007 $ 592.107

Your savings if you have dental coverage

$2,346.00 $2,395.90

The following chart compares costs during the second year of coverage, with potential savings for members needing more extensive dental care.6

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Estimated savings

Description Patients without coverage5 Specialty Duo dental + vision package*,2 out-of-pocket costs($58.60 x 12 months)

Annual individual premium $ 0.00 $ 703.20

Annual dental exam $ 118.00 $ 0.00

Periodic exam $ 101.00 $ 0.00

1st teeth cleaning $ 118.00 $ 0.00

2nd teeth cleaning $ 118.00 $ 0.00

3rd teeth cleaning $ 118.00 $ 0.00

Complete X-rays $ 168.00 $ 0.00

Annual vision exam $ 73.00 $ 0.00

Lenses $ 75.00 $ 25.00

Frames $ 100.00 $ 0.00

Total cost $ 989.00 $ 728.20

Your first-year savings $ 285.80

Specialty Duo dental + vision package2 savings Combining dental and vision needs, Blue Shield’s Specialty Duo dental + vision package can save you money on a wide range of care with our network providers. The examples below show some potential savings in the first year of coverage when using a network dentist and vision care provider. See the Enhanced Dental PPO MS Voluntary 50/1500 plan in the chart on page 3 for additional potential savings during the second year of coverage for the dental component of the dental + vision package.

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Medicare Supplement Plan

Smart reasons to sign upAdvantages

Key features of all Blue Shield Medicare Supplement dental plans:

•Anextensivenetworkofmorethan25,000generalandspecialty care dentist locations in California, and over 218,000 nationwide8

•Threeannualteethcleanings,plusannualX-raysandoralcancer screening covered at 100% when using network providers9

•Nowaitingperiodfordentalcheckups,cleanings,fillings,X-rays,orbasicservices

•Widerangeofmajorrestorativedentalservicesandprocedures,includingcrowns, endodontics, periodontics, oral surgery, and prosthetics at low network rates6

•A$1,000or$1,500permember,percalendar-yearbenefitmaximumfordental network providers, of which up to $750 or $1,000 per member, per year can be used for non-network benefits (depending on dental plan chosen)10

•Choiceofalow$50or$75dentaldeductiblepermember,percalendaryear (depending on dental plan chosen)

Key features of the Medicare Supplement Specialty Duo dental + vision package2:

•IncludesalldentalbenefitsoftheDentalPPO1500plan

•Accesstomorethan6,300ophthalmologists,optometrists,opticians,andretail stores in California, and over 20,000 locations nationwide8

•Choiceofnetworkornon-networkvisionproviders

•A$0copaymentforannualeyeexam

•A$25copaymentformaterialsmaterialssuchaslensesandlow-visionaids

•A$100frameallowancethatcanbeusedtowardsanypairofframes

•Coverageforframesevery24months

•Coverageforlensesorcontactlensesevery24months,or12monthswith a prescription change13, 15

•Benefitfornon-prescriptionsunglassesformemberswhohavehadLASIK or PRK surgery

Strong value

The value of your plan increases further with any additional dental care you receive beyond your annual checkups when compared with the same dental care received without dental coverage up to the annual benefit maximum.

Making it easier

Blue Shield can be your single-source provider for medical and dental, or medical, dental + vision coverage.

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Choose from two dental PPO plans and the dental + vision packageWith a Blue Shield dental PPO plan, you’ll have the freedom to choose any dentist you want. Plus, your out-of-pocket costs for covered services will be lower when using a contracted network provider. For more details, please refer to the following dental plan chart to see the dental plan that suits you best.

Dental PPO highlights matrix

The following information is intended to help you compare coverage benefits and is a summary only. You should consult the Evidence of Coverage and Health Service Agreement for a detailed description of coverage benefits and limitations.

Dental PPO 1500 Dental PPO 1000

Calendar-year (per member)

$50/person $75/person

Calendar-year maximum

$1,500 ($1,000 may be used for non- network dentist)10

$1,000 ($750 may be used for non- network dentist)10

Service Network dentist − Blue Shield

pays

Non-network dentist11 −

Blue Shield pays

Network dentist − Blue Shield

pays

Non-network dentist11 −

Blue Shield pays

Diagnostic and preventive care (not subject to plan deductibles with network and non-network dentists; includes routine oral exams, X-rays, and three teeth cleanings annually)

100% 80% 100% 50%

Basic services (includes anesthesia, palliative treatment, and restorative dentistry)

80% 70% 50% 50%

Major services6

12-month waiting period (includes crown buildups, endodontics, periodontics, oralsurgery, crowns, prosthetics, inlays, onlays, jacket, posts and cores, and veneers)

50% 50% 50% 50%

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Service and eyewear Plan coverage when provided by network providers, after $25 copay

Plan coverage when provided by non-network providers

Comprehensive examination – every 12 months

Ophthalmologic 100% Up to a maximum of $60

Optometric 100% Up to a maximum of $50

Lenses12,13 – every 24 months (or 12 months with a prescription change)

Single-vision 100% Up to a maximum of $43

Bifocal 100% Up to a maximum of $60

Trifocal 100% Up to a maximum of $75

Aphakic or lenticular monofocal 100% Up to a maximum of $120

Aphakic or lenticular multifocal 100% Up to a maximum of $200

Frame – every 24 months Up to a maximum of $10014 Up to a maximum of $40

Contact lenses13,15 – every 24 months (or 12 months with a prescription change)

Non-elective (medically necessary)16

Hard 100% Up to a maximum of $200

Soft 100% Up to a maximum of $250

Elective contact lenses (cosmetic/convenience)

Up to a maximum of $120 Up to a maximum of $120

Plano (non-prescription) sunglasses15,17 Up to a maximum of $10014 Not covered

Specialty Duo dental + vision package for Medicare Supplement plan members*,2

We’ve combined the benefits of the Dental PPO 1500 plan with comprehensive vision benefits into a single package for added convenience. With the Specialty Duo dental + vision package, you also get the freedom to choose the providers of your choice, with access to one of the state’s largest dental networks and one of the state’s largest vision networks. For more details of the dental and vision components of this package, please refer to the benefit highlights below.

Specialty Duo dental plan*,2 highlight matrix

Offers the same benefits highlight as those of the Dental PPO 1500 plan. See the highlights matrix on page 6. For a complete list of the benefits, exclusions, and limitations of the Specialty Duo dental plan, please refer to the Specialty Duo Dental plan for Medicare Supplement members.

Specialty Duo vision plan*,2 highlight matrix

This chart is only a summary. For a complete list of the benefits, exclusions, and limitations of the Specialty Duo vision plan, please refer to the Specialty Duo Vision plan for Medicare Supplement members. There is a 90 day waiting period for vision care services.

* Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).

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Pick a planGreat news! As a current Blue Shield Medicare Supplement plan member, you automatically qualify for our Specialty Duo dental + vision package,*,2 and Dental PPO 1500, and Dental PPO 1000 plans. The value you get with Blue Shield plans can help keep your cost for dental work and for vision care from taking a deep bite out of your wallet.

For two-party agreement holders

If you are enrolled in a Medicare Supplement plan with a two-party agreement, you may enjoy the convenience of a single bill for you and your spouse or domestic partner. Keep the same convenience when you choose your dental plan by matching your dental plan or dental + vision package enrollment with your Medicare Supplement plan enrollment. You and your spouse or domestic partner need to select and both enroll in the same dental PPO plan or dental + vision package to receive one bill that combines Medicare Supplement and dental PPO plan or dental + vision package rates.

If only one of you wants to enroll in the dental PPO plan or dental + vision package, or if you each want different plans, your two-party contract for the Medicare Supplement plan will be affected. In order to enroll in the dental plans in this way, you will need to change your two-party contract and rate to individual contracts and single-party rates, then select the dental PPO or dental + vision package for you and your spouse or domestic partner.

Monthly rates effective January 1, 2014:

Specialty Duo dental + vision package

Dental PPO 1500 Dental PPO 1000

Individual $ 58.60 $ 45.10 $ 35.90

Two-party18 $117.20 $ 90.20 $ 71.80

* Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).

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Medicare Supplement Plan

It’s easy to applyJust fill out the attached enrollment application, sign it, and fax it to us at (209) 367-6490, or mail it back to us today.

If you have any questions, please contact your Blue Shield agent today, or call toll-free (877) 890-7587, 9 a.m. to 4:30 p.m. TTY users can call toll-free (888) 595-0000, 8 a.m. to 6 p.m. weekdays, excluding holidays.

To locate a dental PPO dentist or a vision care provider nationwide, log in to blueshieldca.com, and click Find a Provider. Or for a list of dentists or a vision care provider in your area, contact Member Services at (888) 679-8928 or TTY at (888) 595-0000, 8 a.m. to 5:30 p.m. Monday through Thursday, and 9 a.m. to 5:30 p.m. on Fridays, excluding holidays.

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Dental and dental + vision coverage

1 “Mouth – Body Connection,” American Academy of Periodontology website: www.perio.org/consumer/mbc.top2.htm.

2 Specialty Duo package includes both Specialty Duo dental plan and Specialty Duo vision plan for Medicare Supplement plan members.

3 “Prevent Oral Health Problems: Visit a Dentist Twice a Year,” Academy of General Dentistry, January 2007.

4 “The Eyes are the Windows to Wellness,” Employee Benefit News, August 1, 2009.

5 The dental rates are based on a 90% average of fees charged in San Francisco by the 2012 National Dental Advisory Services. Vision costs are based on average out-of-pocket retail cost for vision exam, eyewear lenses, and frames.

6 Dental PPO 1000, Dental PPO 1500, and Specialty Duo dental plan for Medicare Supplement plan members have a 12-month waiting period for major restorative services and procedures (such as crowns), endodontics, periodontics, oral surgery, and removable or fixed prosthetics.

7 MAC is Maximum Allowable Charge of providers in the area. MAC payments shown are for San Francisco, California, as listed in the 2012 National Dental Advisory Service Comprehensive Fee Report. They are an estimate for illustrative purposes, based on fees negotiated with dentists participating in the network. The member’s dentist may have negotiated a different fee. The MAC may be updated periodically and is subject to change. When a member uses a non-network dentist, the plan reimburses up to the MAC amount; if that provider charges more than the MAC rate, the member is responsible for the difference.

8 Dental providers in and out of California are available through a contracted dental plan administrator. Vision providers in and out of California are available through a contracted vision plan administrator.

9 The third annual teeth-cleaning benefit is available with the Dental PPO 1000, Dental PPO 1500, and Specialty Duo dental plan for Medicare Supplement plan members.

10 Each calendar year, the member is responsible for all charges incurred after the plan has paid these amounts for covered dental services.

11 The coinsurance percentage indicated is a percentage of allowed amounts that we pay to providers. Non-network providers can charge more than our allowable amount. When members use non-network providers, they must pay the applicable copayment/coinsurance plus any amount that exceeds our allowable amount. Charges in excess of the allowable amount do not count toward the calendar-year deductible or copayment maximum.

12 Each pair of lenses includes a pink or rose tint No. 1 or No. 2 in the allowance and up to 61 mm in size.

13 A prescription change means any of the following: a change in prescription of 0.50 diopter or more; a shift in axis of astigmatism of 15 degrees; a difference in vertical prism greater than 1 prism diopter; or a change in lens type.

14 When the participating provider uses wholesale or warehouse pricing, the maximum allowable frame allowance will be as follows: wholesale allowance – $66.04; warehouse allowance – $69.09. Note that this pricing replaces the frame allowance shown in the Summary of Benefits. Network providers using wholesale or warehouse pricing are identified in the Directory of Network Vision Providers. You pay any cost above the allowed amount.

15 In lieu of lenses and frame.

16 A report from the provider and prior authorization from a contracted vision plan administrator is required.

17 For members who have had PRK, LASIK, or custom LASIK vision correction surgery only, this benefit of plano sunglasses allowance is equal to the plan’s frame allowance. An eye exam by a network provider is required to verify laser surgery or a note from the surgeon who performed the laser surgery is required to verify laser surgery. Available once every 24 months.

18 If you have a two-party Medicare Supplement plan contract, you and your spouse/domestic partner need to select and both enroll in the same dental PPO plan or dental + vision package in order to receive one bill that combines Medicare Supplement plan and dental PPO plan or dental + vision package rates.

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Dental PPO Plan Enrollment Form for Blue Shield Medicare Supplement Plan MembersSubscriber name (first, last): __________________________________________________________________________________

Blue Shield subscriber ID number: ___________________________________________________________________________

Address: _____________________________________________________________________________________________________

City: _______________________________________________________________________ State: ______ ZIP: _______________

Medicare supplement plan contract type: ¨ Individual ¨ Two-party (see Section 2 below)

1. Dental plan option:

¨ Dental PPO 1000 ¨ Dental PPO 1500 ¨ Specialty Duo dental + vision package*

2. Two-party enrollment: Must be completed if you have a two-party agreement. If you have a two-party Medicare Supplement plan contract with Blue Shield, you and your spouse or domestic partner need to both select and enroll in the same dental PPO plan or dental + vision package. Important: If only one of you wants to enroll in a dental PPO plan or dental + vision package, or if you each want different dental PPO plans or dental + vision package (as indicated by selecting a different plan option in this Section 2), your two-party contract for the Medicare Supplement plan will be affected. If no dental plan is selected, or if a different dental plan option is selected for the spouse/domestic partner below, you are requesting Blue Shield to change your two-party contract and rate to individual contracts and single party rates.

Spouse/domestic partner name (first, last): _______________________________________________________________

Spouse/domestic partner dental plan option:

¨ Dental PPO 1000 ¨ Dental PPO 1500 ¨ Specialty Duo dental + vision package* ¨ None

3. Terms and conditions acknowledgment

Before submitting this enrollment form, please read the following acknowledgments and confirm your agreement with your signature and date below:

a. I confirm that I am, or will be, at the time of enrollment in this dental PPO plan or dental + vision package, a Blue Shield Medicare supplement plan member.

b. I understand that if my dental plan or dental + vision coverage is cancelled for any reason (by me or by Blue Shield), I will have to wait six months to reapply for coverage.

c. I understand that if my Blue Shield Medicare Supplement plan coverage is terminated, this dental plan or dental + vision coverage will also terminate.

d. I understand that Blue Shield will notify me of my effective date of coverage and any charges for services received prior to my effective date or after termination of coverage are not covered.

I have read the summary of benefits and each of the terms and conditions of coverage set forth above. I understand and agree to each of them. To the best of my knowledge and belief, information and confirmations provided on this form are correct and true.

Subscriber’s signature ____________________________________________________________ Date __________________

Spouse/domestic partner’s signature ______________________________________________ Date __________________

* Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Specialty Duo package includes both Specialty Duo Dental Plan and Specialty Duo Vision Plan for Medicare Supplement plan members.

Please fax or mail the completed and signed application to:

Installation & Billing, Blue Shield of California P.O. Box 3008 Lodi, CA 95241-1912

Fax: (209) 367-6391

For internal use only

DSA name:

DSA number:

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